Mai Huang: A 64-Year-Old Waitress With Left-Sided Abdominal Pain and Fever

Mai Huang

Mai Huang is a 64-year-old waitress with the chief complaint of, “My belly hurts.” Mai stated that over the past week or so, she felt constipated, and for the last few days, she’s been experiencing crampy pain in her left lower abdomen. Mai stated that she woke up today feeling like she had the stomach flu and felt like she had a fever. She called her daughter, who said that Mai probably had appendicitis and that she needed to go to the emergency room. Instead she called our office, and we worked her in. “Doctor, I am so sorry to bother you. I am sure this is nothing. I just wanted to be able to tell my daughter Sally that it was just the flu. You know how daughters can be.” I reassured her that I understood and would do everything I could to get things sorted out, and if she wanted I’d be happy to give Sally a call. “So, Mai, have you ever had anything like this before?” She said, “No Doctor, never.” I asked, “Have you had any previous abdominal pain?” She replied, “No, never.”

I asked Mai what made the pain worse, and she said that when she came over to the office on the bus, every time the bus hit a bump, it would jar her belly and make it hurt. “Also, Doctor, and this is embarrassing, I am having a lot of gas.” I asked, “Anything else?” She said that she felt like she was bloated, but really any activity made the pain worse. I asked her what made the pain better, and she said that she tried to drink some hot tea because she didn’t have much of an appetite, but the pain just wasn’t getting any better. In fact, it seemed to be a little worse. Mai denied significant sleep disturbance.

I asked Mai to point with one finger to show me where it hurt the most, and she immediately pointed to her left lower quadrant.

On physical examination, Mai was febrile, with a temperature of 100.6°F. Her respirations were 18, and her pulse was 78 and regular. Her blood pressure was 106/72. Mai’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed tenderness in the left lower quadrant, and I thought that I could feel a mass. Bowel sounds were diminished, with no organomegaly. Mai had mild costovertebral angle (CVA) tenderness on the left. There was no peripheral edema. Her low back examination was normal. Visual inspection of the abdomen was unremarkable. A careful neurologic examination was normal.

Key Clinical Points—What’s Important and What’s Not